Letter to the Editor: “Clinical Outcomes of Percutaneous Coronary Intervention Using Excimer Laser Coronary Atherectomy for Complex Coronary Lesions: The ACCELERATE Registry”

We read with great interest the article by Tomasello et al. entitled “Clinical Outcomes of Percutaneous Coronary Intervention Using Excimer Laser Coronary Atherectomy for Complex Coronary Lesions: The ACCELERATE Registry” [1]. This prospective multicentre registry provides valuable real-world evidence on the use of Excimer Laser Coronary Atherectomy (ELCA) in the management of complex coronary lesions—a topic of considerable clinical relevance given the increasing prevalence of heavily calcified and resistant coronary stenoses. The authors are to be commended for their meticulous data collection, clear presentation of procedural and long-term outcomes, and their efforts to advance understanding of ELCA's role in modern Percutaneous Coronary Intervention (PCI). Their findings highlight impressive procedural success rates and long-term safety outcomes that contribute meaningfully to the growing body of evidence supporting laser atherectomy as a viable adjunctive technique in PCI. However, despite these valuable contributions, the study has the following limitations that warrant further consideration and discussion. First, a major limitation is device and procedural heterogeneity. The use of multiple ELCA systems (Spectranetics vs. Philips Nexcimer) and variable energy settings (30–80 mJ/mm², 25–80 Hz) may cause inconsistent ablation results, affecting lesion modification and complication rates. Such heterogeneity makes it difficult to attribute outcomes solely to ELCA efficacy. For example, Protty et al. found that device-setting variability limited interpretation in the British Cardiovascular Intervention Society (BCIS) ELCA registry [2]. Second, lack of standardization in operator expertise and center experience may have influenced outcomes, given ELCA's steep learning curve. Differences in experience across centers could introduce performance bias, leading to overestimation of safety and success. A systematic review by Chaudhri et al. noted significant heterogeneity in outcomes due to operator experience and procedural technique, limiting the generalizability of ELCA results [3]. Third, the absence of a control group is notable. Without comparison to other calcium modification strategies (e.g., rotational/orbital atherectomy, IVL, or cutting balloons), success rates cannot be confidently attributed to ELCA superiority, limiting causal inference and potentially inflating perceived benefits. A meta-analysis by Khattak et al. highlighted the need for direct comparative data to clarify relative safety and efficacy [4]. Lastly, there was a lack of patient-level adverse event adjudication. Events such as MACE, no-reflow, or perforation were self-reported without blinded review, introducing information bias and possible underreporting. Tsutsui et al. emphasized the importance of independent event adjudication in registry data to avoid underestimation of periprocedural complications [5]. To improve future ELCA research, multicentre studies should ensure methodological consistency and procedural standardization through uniform laser protocols, detailed reporting, and core-lab adjudication. Outcomes should be stratified by operator experience with appropriate training and certification to reduce variability. Randomized or matched trials comparing ELCA with other atherectomy methods and routine OCT/IVUS-based lesion assessments will further enhance accuracy and guide lesion-specific, evidence-based practice. In conclusion, Tomasello et al. [1] provide valuable insights into ELCA in complex PCI; however, unresolved methodological issues may limit generalizability. Future studies with standardized methods, trained operators, and comparative designs are needed to validate ELCA's clinical value and ensure its consistent, evidence-based use. The authors have nothing to report. The authors have nothing to report. The authors declare no conflicts of interest. During the preparation of this study, the authors used open AI's ChatGPT to improve the written manuscript. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication. Data sharing does not apply to this article as no datasets were generated during the current study; all data were sourced from published literature.